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Society's Choices: Social and Ethical Decision Making in Biomedicine
A recently created organization called the American Association of Bioethics (AAB) aims to provide a forum for collaboration among varied professional societies in addressing ethical issues confronted in health science and health care. The AAB board is composed of representatives from the AMA, ACP, AHA, American Bar Association, and other professional organizations, as well as several bioethicists.
Health Maintenance Organizations
In addition to the efforts of medical associations, individual HMOs, motivated primarily by desires to reduce costs and simultaneously preserve a reasonable standard of care, have made several efforts to guide physicians and patients in their use of biomedical technology. Group Health of Puget Sound (GHPS) developed a preventive care manual for its primary care practitioners and has attempted to involve subscribers to the health plan in decisions about the allocation of resources. The manual includes, for example, risk-based guidelines for preventive services such as mammograms. Harvard Community Health Plan (HCHP) has also developed scientifically based clinical algorithms.
Challenges Presented by the Creation of Guidelines
All of these efforts to provide physicians with up-to-date information and guidance are welcome, particularly in light of limited governmental action in many areas. However, such efforts have not been without problems. Guidelines are devised by a variety of groups for a variety of purposes, and the resulting welter of guidelines can often be inconsistent and thus confusing. First, guidelines are sometimes not based on universally accepted scientific evidence. Second, they are sometimes haphazardly and inefficiently disseminated to their intended users. Third, they are sometimes offensive to physicians, who may not be receptive to guidelines that do not mesh well with their practice and experience. Fourth, the various guidelines may offer competing and contradictory advice, presenting practitioners with additional ethical problems (IOM, 1992). For example, AMA and ACOG offer conflicting guidance on the handling of surrogate motherhood: AMA disapproves of the practice and advises against involvement in it (AMA, 1992a), while ACOG regards it as a difficult but potentially acceptable pregnancy option (ACOG, 1990). Fifth, such guidelines often do not incorporate patient preferences. Finally, the professional self-interest of some groups may inadvertently inform and bias their specific recommendations.
IOM examined many of these issues in a 1992 report on the difficulties encountered by the Agency for Health Care Policy and Research (AHCPR)